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Pulmonary Talc Granulomatosis - Unusual Cause of Pulmonary Infiltrates in HIV Patient FREE TO VIEW

Anand Kommuri*, MD; Nikhil Madan, MD; Misti Coronel, MD; Rohit Kumar, MD; John Farber, MD
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Thomas Jefferson University Hospital, Philadelphia, PA

Chest. 2012;142(4_MeetingAbstracts):270A. doi:10.1378/chest.1390718
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SESSION TYPE: Infectious Disease Cases III

PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Pulmonary talc granulomatosis has been reported in intravenous drug abusers who inject oral drugs and rarely with inhaled crack cocaine.We report a case of pulmonary talc granulomatosis in a HIV patient with new pulmonary infiltrates

CASE PRESENTATION: A 55 year old male with prior history of chronic obstructive airways disease (COPD), hepatitis C, HIV infection, ventilator dependent respiratory failure (2006) status post tracheostomy and decannulation( 2007) ,recent tracheostomy for tracheal stenosis 1 month ago for several weeks` history of progressive dyspnea and productive cough was admitted to the hospital with worsening dyspnea and hemoptysis. He was transferred to critical care unit for ventilator dependent respiratory failure. He was an active smoker (marijuana), inhaled crack cocaine but denied intravenous drug use. His current medications include tiotropium bromide, albuterol for COPD and antiretroviral therapy for HIV infection. Physical examination revealed a sick man in respiratory distress on volume control ventilation. He had decreased air entry diffusely with end inspiratory crackles in the left lung base. He had a normal white count, elevated creatinine (1.4mg/dl) ,and abnormal liver function tests. Blood and urine cultures, viral panel were negative; sputum culture grew aspergillus ( light growth). A CT scan chest showed a stable right upper cavitary lesion, emphysema and new left upper lobe infiltrate . He was started on antifungal therapy. However, a transbronchial biopsy of the new infiltrates in the left lung showed nonnecrotizing granulomas with birefringent crystals under polarizing light ( talc) suggesting recent drug use. Patient`s clinical course was further complicated by multiorgan failure and he died after family withdrew care

DISCUSSION: Pulmonary talc granulomatosis is a granulommatous inflammation caused by insoluble fillers ( talc, starch) injected or inhaled with recreational drugs.Demonstration of talc crystals in the granulomas provides a definitive diagnosis.In HIV patients, it mimics opportunistic, atypical and fungal infections; granulomatous diseases like sarcoidosis. The size of the particles and location of granulomas in may help in differentiating between intravenous and inhalational routes. In our patient, a history of recent drug use was not forthcoming but was confirmed on biopsy of the new infiltrates.

CONCLUSIONS: Pulmonary infiltrates in a HIV patient has a wide differential diagnosis of infectious and non infectious etiologies Pulmonary talc Granulomatosis should be considered in the differential diagnosis of new pulmonary infiltrates in a HIV patient with a history of prior drug use

1) Pulmonary effects of illicit drug use Wolff etal Clin Chest Med 25 (2004) 203-216

2) Talcosis Presenting as Pulmonary Infiltrates in an HIV-Positive Heroin Addict. Ben-Haim, M.D. etal (Chest 1988; 94:656-58)

3) Pulmonary Talc Granulomatosis in a Cocaine Sniffer Marwan Oubeid etal CHEST / 98 / 1 I JULY, 1990

DISCLOSURE: The following authors have nothing to disclose: Anand Kommuri, Nikhil Madan, Misti Coronel, Rohit Kumar, John Farber

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Thomas Jefferson University Hospital, Philadelphia, PA




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